inforMED
MalfunctionKQW

CD HORIZON SPINAL SYSTEM

Received Jul 17, 2018 · Event occurred Jun 20, 2018

Report 1030489-2018-01010 · MDR key 7693327

Device

Generic name

Goniometer, Nonpowered

Model number

NA

Catalog number

5484805

Lot number

RS11M037

Product problems

  • Disconnection
  • Mechanical Problem
  • Disconnection

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

PRODUCT WAS NOT RETURNED TO THE MANUFACTURER FOR EVALUATION. THEREFORE, WE ARE UNABLE TO DETERMINE THE DEFINITIVE CAUSE OF THE R EPORTED EVENT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.

Description of Event or Problem

PRE-OP DIAGNOSIS: LUMBAR SPINAL CANAL STENOSIS PROCEDURE: TRANSFORAMINAL LUMBAR INTERBODY FUSION (TLIF) LEVELS IMPLANTED: L3/4/5 IT WAS REPORTED THAT ON (B)(6) 2018, INTRA-OP, THE SCREWS WERE INSERTED WITHOUT PROBLEM AT FIRST, AND 4MM REDUCTION SCREW WAS PLACED ONLY FOR L3. THERE WAS ALSO NO PROBLEM WITH INSERTING THE ROD, AND IT WAS PLACED ON L4/5 UNTIL "RD" AND PROVISIONAL FIXATION WAS PERFORMED, AND THERE WAS NO PROBLEM WITH THE PROVISIONAL FIXATION ON THE LEFT SIDE. THE PROVISIONAL FIXATION WAS PERFORMED ON THE RIGHT SIDE OF L4, AND WHEN L5 SET SCREW WAS ATTEMPTED TO BE INSERTED, THE SITUATION WAS THAT IT COULD NOT BE TIGHTENED UNTIL THE END ALTHOUGH IT GRIPPED IN THE MIDDLE. WHEN THE SET SCREW WAS CHECKED, IT WAS CONFIRMED THAT IT WAS GOUGED. NO MATTER HOW MANY TIMES THE SURGEON TRIED WITH NEW SET SCREWS, THERE WAS NO EFFECT. IT WAS SUSPECTED THAT THERE MIGHT BE SOMETHING WRONG WITH THE SCREW HEAD. THEREFORE, THE SCREW WAS REMOVED AND REPLACED WITH A NEW SCREW, AND THE NEW SCREW WAS INSERTED AGAIN. THE ROD WAS PLACED AND THE PROVISIONAL FIXATION WAS ATTEMPTED TO BE PERFORMED, BUT IT COULD NOT BE PERFORMED AGAIN ON THE RIGHT SIDE OF L5. WHEN CHECKING IT BY IMAGE, IT WAS OBVIOUS THAT THE EXTENDER WAS DISENGAGED, SO THE SCREW WAS REMOVED AGAIN. AS THERE WAS A BACKUP EXTENDER, THIS ONE WAS USED INSTEAD, AND THEN THERE WAS NO PROBLEM WITH THE TIGHTENING. NO PATIENT COMPLICATIONS WERE REPORTED AS A RESULT OF THIS EVENT.

Additional Manufacturer Narrative

IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.